The Health Care Safety Net and Crowd-Out of Private Health Insurance

There is an extensive literature on the extent to which public health insurance coverage through Medicaid induces less private health insurance coverage. However, little is known about the effect of other components of the health care safety net in crowding out private coverage. We examine the effect of Medicaid and uncompensated care provided by clinics and hospitals on insurance coverage. We construct a long panel of metropolitan area and state-level data on hospital uncompensated care and free and reduced price care offered by Federally Qualified Health Centers. We match this information to individual level data on coverage from the Current Population Survey for two distinct groups: children aged 14 and under and single, childless adults aged 18 to 64. Our results provide mixed evidence on the extent of crowd-out. Hospital uncompensated care does not appear to crowd-out health insurance coverage and health center uncompensated care appears to crowd-out private coverage for adults and, in some specifications, children.

How Managed Care Affects Medicaid Utilization: A Synthetic Difference-in-Differences Zero-Inflated Count Model

We develop a synthetic difference-in-differences statistical design to apply to experimental data for adult women living in Hennepin County, Minnesota, to estimate the impact of Medicaid managed care on various modes of medical care use. Because the outcomes of interest are utilization counts with many persons using none of a particular mode of care we use count regression models that are adjusted for excessive zeros. We find no reductions in physician visits or hospital inpatient and emergency department care use, but reductions in hospital outpatient care. Simulations designed to judge the economic significance of our results suggest a program effect that is a savings of about ten percent

The Effects of Consumer-Directed Health Plans on Health Care Spending

We use unique data from an insurer that exclusively offers high-deductible, "consumer-directed" health plans to identify the effect of plan features, notably the spending account, on health care spending. Our results show that the marginal dollar in the spending account is entirely spent on outpatient and pharmacy services. In contrast, inpatient and out-of-pocket spending were not responsive to the amount in the spending account. Our results represent the first plausibly causal estimates of the components of consumer-driven health plans on health spending. The magnitudes of the effects suggest important moral hazard consequences to higher spending account levels.

The Price of Palliative Care: Towards a Complete Accounting of Costs and Benefits

The costs and benefits of hospice and palliative care have recently received attention for many compelling reasons. First, the cost of medical care over a lifetime is largely expended near the end-of-life. The impending demographic bulge of aging baby boomers will only heighten concerns about costs. Second, hospice and palliative care have been offered as potential vehicles for reducing late-in-life spending. Third, palliative care has gained legitimacy as a distinct medical specialty, having as it does a characteristic philosophy, specialized skill sets, and specific service delivery needs. This philosophy of care is consistent with and, to some degree, builds on the philosophy of care that geriatrics also promotes. In this article, currently accepted standards for cost-benefit analysis of health care interventions are outlined, and a framework to evaluate palliative care within these standards is provided. Recent publications on the economic implications of palliative care are reviewed, which are only the ‘‘tip of the iceberg’’ of the potential costs and benefits. Using this framework, the authors offer guidelines for performing comprehensive cost-benefit analyses of palliative care and conclude that many of the issues beneath the surface may be substantial and deserving of closer scrutiny. Methods for gathering relevant cost-benefit information are detailed, along with potential obstacles to implementation. This approach is applicable to palliative care in general, including palliative care for elders

The Price of Palliative Care: Towards a Complete Accounting of Costs and Benefits

The costs and benefits of hospice and palliative care have recently received attention for many compelling reasons. First, the cost of medical care over a lifetime is largely expended near the end-of-life. The impending demographic bulge of aging baby boomers will only heighten concerns about costs. Second, hospice and palliative care have been offered as potential vehicles for reducing late-in-life spending. Third, palliative care has gained legitimacy as a distinct medical specialty, having as it does a characteristic philosophy, specialized skill sets, and specific service delivery needs. This philosophy of care is consistent with and, to some degree, builds on the philosophy of care that geriatrics also promotes. In this article, currently accepted standards for cost-benefit analysis of health care interventions are outlined, and a framework to evaluate palliative care within these standards is provided. Recent publications on the economic implications of palliative care are reviewed, which are only the ‘‘tip of the iceberg’’ of the potential costs and benefits. Using this framework, the authors offer guidelines for performing comprehensive cost-benefit analyses of palliative care and conclude that many of the issues beneath the surface may be substantial and deserving of closer scrutiny. Methods for gathering relevant cost-benefit information are detailed, along with potential obstacles to implementation. This approach is applicable to palliative care in general, including palliative care for elders

Does Informal Care from Adult Children Reduce Nursing Home Admissions for the Elderly?

Despite the policy importance, particularly as society ages, little is known about the impact of informal care on nursing home admissions. This paper jointly models the receipt of regular help from adult children and subsequent nursing home care, using data from the Study of Asset and Health Dynamics Among the Oldest Old (AHEAD). Results indicate that frequent help from children with basic personal care reduces the likelihood of nursing home use over a subsequent two-year period by about 60% for disabled Americans age 70 and older. However, we found no significant reduction in nursing home admissions when help was measured more broadly to include assistance with chores and errands

The Health Care Safety Net and Crowd-Out of Private Health Insurance,” Working Paper

There is an extensive literature on the extent to which public health insurance coverage through Medicaid induces less private health insurance coverage. However, little is known about the effect of other components of the health care safety net in crowding out private coverage. We examine the effect of Medicaid and uncompensated care provided by clinics and hospitals on insurance coverage. We construct a long panel of metropolitan area data on hospital uncompensated care and free and reduced price care offered by Federally Qualified Health Centers. We match this information to individual level data on coverage from the Current Population Survey. Our preliminary results provide mixed evidence on the extent of crowd-out. Hospital care appears to have little crowd-out effect, but clinic care does substantially crowd out private coverage in some specifications. We are also able to examine other hypotheses on takeup and crowd-out using our individual data and metropolitan area level characteristics. The authors gratefully acknowledge financial support provided by the Robert Wood Johnso

The Impact of Elder Care on Women's Labor Supply

Adult daughters traditionally have served as primary caregivers for frail unmarried adults, but the levels of care they have provided in the past may interfere with their growing work responsibilities. This paper examines the impact of time transfers to elderly parents on labor supply at midlife. Using a sample of women ages 55 to 67 in the Health and Retirement Study, we estimate panel data models of annual hours of paid work controlling for the endogeneity of time assistance to parents. The results indicate that time help to parents strongly reduces female labor supply at midlife